Dilutional Coagulopathy, an Underestimated Problem?

Abstract

When no fresh frozen plasma is available, acute major blood loss is compensated above all with crystalloids, colloids, and erythrocyte concentrates, meaning that all plasma clotting factors are diluted. Consumption coagulopathy is almost always accompanied by dilutional coagulopathy. Formulas for calculating critical blood loss and standard coagulation tests are often not helpful in the case of massive transfusion. On the other hand, systems suitable for point of care, such as thrombelastography, have important advantages. In the case of consumption and dilutional coagulopathy plasma coagulation is disturbed, and critical values are first seen for fibrinogen. Fibrin polymerization is not only impaired by the bleeding-induced loss and dilution of fibrinogen but also by interaction with artificial colloids, particularly hydroxyethyl starch preparations. Therapy of consumption and dilutional coagulopathy calls for fresh frozen plasma. If this is not available in sufficient quantity or within a reasonable time, coagulation factor concentrates must be used. Neither fresh frozen plasma therapy nor treatment with coagulation factor concentrates has been the subject of detailed clinical study. Further studies are needed to work out guidelines for coagulation management in the case of massive blood loss.

Bleeding risk assessment using whole blood impedance aggregometry and rotational thromboelastometry in patients following cardiac surgery

“…[7]. Extracorporeal circulation and heparin may induce many abnormalities in the coagulation system, including thrombocytopenia [2], platelet dysfunction [8,9], coagulation factor deficiencies [10], residual heparin after protamine administration [11], and fibrinolysis [12].…”

The value of rotation thromboelastometry to monitor disturbed perioperative haemostasis and bleeding risk in patients with cardiopulmonary bypass

“…There are some reports [4][5][6]15,18,19] indicating that FIBTEM may help identify patients who may bleed due to extremely low fibrinogen level and that may benefit when treated with FFP, or benefit even more from fibrinogen substitution. We were therefore interested to find out to what extent a MCF in FIBTEM below 8 mm was associated with alterations in other ROTEM variables, particularly in EXTEM as the basis of FIBTEM.…”

“…In addition to the administration of anticoagulants and hypothermia, contact of blood with the membrane system results not only in activation of platelets, clotting and fibrinolytic factors but also in activation of the complement and kallikrein systems, as well as of leukocytes with consequent release of cytokines and other mediators of inflammation [2,3]. Loss of reactive platelets, consumption of coagulation factors, the haemodilution due to the CPB priming procedure and the intraoperative volume substitution decrease the haemostatic potential and increase the risk for intraoperative and postoperative bleeding [4].…”

Tranexamic Acid: Implementing a Clinical Guideline for its use in a Moderate Resource Setting

“…Trauma-induced coagulopathy is different from disseminated intravascular coagulation (DIC). DIC is characterized by generalized intravascular micro coagulation with subsequent factor consumption whereas in acute traumatic coagulopathy, there is a bleeding-related loss of coagulation factors and platelets 11 .…”